Sunday, April 26, 2015

Do you think that physicians’ advice should be based on their patients’ best interests? How about lawyers? Plumbers? Financial brokers?

An advisor who has what is termed a fiduciary duty is required to use the best interest standard with his client. For example, an attorney is prohibited from recommending that his client proceed to trial, which would be beneficial financially to the lawyer, if the attorney believes that a settlement serves his client’s interest better. While it may not always work this way in the real world, this is how it is supposed to happen.

"Toilet's clogged, ma'am. Better replace the whole thing."

Shockingly, investment brokers, unlike certified financial planners, have no fiduciary responsibility when advising clients on their personal investments. They are free to make financial recommendations that are ‘suitable’ for a client, even if this would not be in the client’s best interest. The broker can consider his own financial interest, which clearly may conflict with his client’s welfare, without violating any professional standards.

I wonder how many clients of brokers are aware of this scam? The Security and Exchange Commission now has this legalized lapse under review and is expected to issue a regulation later this year, hopefully, raising brokers’ standards to what they should have been all along.

Imagine if all of society operated under these loose rules.

Electrician

Broker Standard: Looks like you need a new fixture.

Fiduciary: Looks like you need a new light bulb

Auto Mechanic

Broker Standard: The transmission needs to be replaced.

Fiduciary:I think a new spark plug should do it.

Taxi Driver

Broker Standard: New in town? Let me show you the sights on our way to your hotel.

Fiduciary:Hop in. We’re only 5 minutes away.

Physician

Broker Standard:I think a gastric bypass makes the most sense here.

Fiduciary:I’ve arranged for you to meet with our dietican.

Relax, my patients. Physicians are fiduciaries and are obligated to consider only your best interest, not ours, when we are offering you medical advice. Even if we weren’t true fiduciaries, I’d like to think we’d do the right thing anyway.

Sunday, April 19, 2015

I love teachers. And, I love the teaching profession. I
remember years ago teaching one class to middle-schoolers on a subject that I
thought exuded fascination and drama – the Civil War. It was a long 50 minutes. Even my daughter was doing her best to feign
interest. While the fault here may have
been with the guest instructor, the lesson for me, which I have not forgotten, is
how tough the teaching trade is.

Teaching - Leave it to the Professionals

I don’t have the same affection for the teachers’ unions as
I do for the profession. Their unions
are advocacy groups to protect the interests of its members. There is nothing wrong with this. Many professions and occupations, including
mine, have similar societies to whom constituents pay money in exchange for various job protections.

My issue with these groups is when they torture the truth to
disguise the real reason for their positions.
Of course, even the most disinterested spectator can see through this
charade. How many times, for example,
have we heard teachers’ unions championing a position claiming that ‘this is
for our kids’, when it’s really for the teachers. Just tell the truth. If teachers oppose a proposal that threatens
their livelihood, then just say so. Let me
illustrate.

A state government facing budgetary challenges
floats a proposal to freeze teacher pay for 3 years.

Here’s what the teachers’ union says:

We will oppose any effort that threatens the education of
our kids.

Here’s what they should say.

We will oppose any effort that threatens our
compensation. We work hard every day and
deserve to be paid fairly for it. We hope the public will support us.

To those educators who are now seething at my holier than
thou perspective, calm down. Physicians
are no better. The American Medical
Association, which I have not joined, issues the same bromides about
‘protecting patients’ when they are really aiming to ‘protect doctors’. Again, nothing wrong with this mission. Just tell the truth.

Recently, the Texas Medical Board is trying to restrict telemedicine in that state. Leaving
aside the merits and drawbacks of telemedicine, its expansion is
inevitable. Technology vanquishes every
obstacle. Readers here know of my deep
concern that medical technology has sacrificed a large measure of our humanity. Most patients and doctors will agree that
electronic medical records, for example, have not burnished the doctor–patient
relationship. The Texas Medical Board’s
language suggests that their concern is that telemedicine will threaten
the doctor-patient relationship. Come on
folks, fess up. Just say plainly that
you don’t want out-of-town teledocs threatening the incomes of Texas
physicians. While the truth might not
set you free, at least your credibility would be preserved.

Why do I write this blog.
It has nothing to do with my ego, of course. ‘I do it only to serve my readers.’

Sunday, April 12, 2015

A female patient came to see me with some difficulty
swallowing, a very routine issue for a gastroenterologist. I performed an scope examination of her
esophagus and confronted a huge cancer occupying the lower portion of her
esophagus.

Life changes in an instant.

I expected a benign explanation for her swallowing
issue. She was relatively young and not
particularly ill. She had seen my
partner years in the past for a similar complaint, which he effectively treated
by stretching her esophagus. I expected
that I my procedure would be a re-run. I
was wrong.

Prior to the procedure, we chatted and I learned that she
had recently undergone a CAT scan of the chest ordered in response to some
respiratory symptoms, which were not severe.
After I had completed my scope examination of her, I was amazed that no mention of this tumor
was related to the patient, who had told me that only a hiatal hernia was seen.

I requested a fax of the report which confirmed that the
radiologist made no mention of an esophageal abnormality. I assumed that this scan was not interpreted
properly by the radiologist who somehow missed this large, consequential mass
in the esophagus. Fortunately, this
error caused no harm as I found the cancer just 2 weeks later.

I called the senior radiologist at the hospital as I wanted
him to review the scan and to implement whatever internal quality control
procedures that existed. I would want
the same effort expended if I had missed a lesion or committed a medical error. He reviewed the scan he agreed with the
original radiologist’s interpretation.
He explained to me how in this case the tumor appeared just like a
benign hiatal hernia. If any reader is
suspected that this guy is just covering for her colleague, I verify that this
is not the case. The radiologist I
called is irreproachable.

Usually, we face the opposite scenario from
radiologist. They find lesions
everywhere that are benign, but send patients and their doctors on cascade into
chaos.

I believe that the cancer, which developed in such a stealth
fashion in my patient, also hid from the radiologist.

My point here for patients is that scans are imperfect. They can miss stuff that matters and uncover
stuff that means nothing, the more common outcome. It’s a reminder that the practice of
medicine is imperfect and offers no guarantees even when it is performed
well. This vignette reminds me how important it
is to listen carefully to the patient. The scans, labs and even the colonoscopies might be wrong.

If I’m worried about a patient, but the data all scream that
he is healthy, should I relax? If a
patient feels superb, but the scan shows something found by accident, do I
sharpen up the scalpel?

Sunday, April 5, 2015

There’s nothing like discrimination – true or imagined – to keep
our airwaves humming. Earlier in the
week, Indiana and then Arkansas were media fodder for laws that were proposed to
protect religious freedom. Yes, I know
the other side of the argument, that these ‘religious freedom’ protections were
veiled attempts to discriminate against the LGBT community. Both states raced to revise their original laws, although the laws' backers deny any
discriminatory intent or effect.

It was likely that these governors feared an economic riposte from large companies who have expressed concern and disapproval over the perceived discriminatory effects of religious freedom laws. I wonder how many of these companies do business with or remain silent about countries that use child labor, discriminate against women, have no freedom of speech or make homosexuality a crime.

Realize that the original RFRA proposals do not guarantee an outcome in any dispute, a point that I believe is widely misunderstood. For example, the law would not
make it legal for a florist to deny service to a gay wedding. It would permit the florist to allege in
court that such a service would constitute a significant burden on his
religious beliefs. If I were the sitting
judge, I would likely rule against the florist as I do not accept that selling
flowers assaults one’s religious tenets. Just because a person claims his religion is
being attacked, doesn’t make it so.

Everyone deserves flowers.

Some acts of discrimination get a free pass.

Ivy League
institutions discriminate against students with lower SAT scores

Of course, I’m not entirely
seriously here. I do not think that anyone
should face discrimination for who they are. Indeed, I wish our society were closer to a
meritocracy. Sometimes, the reason that
an individual does not get a job promotion, make the team, get the lead role in
a play or get acquitted at trial is because the person doesn’t deserve it. I don’t deny the existence of prejudicial
behavior and bigotry, but they should not be invoked by default when a person
is denied a desired outcome. Sometimes folks are fired because they should be.

Should a tattoo artist be able to
refuse to ink ‘I Hate Jews’ on someone’s chest?
What if an atheist wants body art with bold lettering of ‘I Hate Jesus’? The Supreme Court decided in the Hobby Lobby case that a private business can deny services for religious reasons under certain circumstances.

When can a private business lawfully refuse service to a customer?

What about physicians?
Do we have to treat every person who makes an appointment to see
us? I don’t know the private beliefs of
my patients, but I’m sure they are a
cross section of society with all the prejudices that one would expect. If I knew for certain that a patient was a
homophobe or a racist or an anti-Semite, should I discharge this person from my practice? Could a pro-life physician ethically discharge a
pro-choice activist from his practice?
Could this doctor justify this decision by his belief that the patient advocates murder and that a healthful
doctor-patient relationship would not be possible? Or, should doctors see everyone as our
mission to heal and comfort transcends personal beliefs and practices?

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About Me

I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies.